Bladder Cancer

Bladder cancer is a disease in which malignant (cancer) cells form in the tissues of the bladder.

Specialists at City of Hope are internationally recognized experts in the treatment of bladder cancer. As one of a handful of institutes to attain the elite designation of
Comprehensive Cancer Center by the National Cancer Institute,
City of Hope is acknowledged as a leader in cancer research and treatment.

City of Hope also offers numerous
bladder cancer clinical trials
and is constantly working to develop and deliver the latest treatment strategies for any stage of bladder cancer.

Bladder Cancer Treatment Highlights

We are among the most experienced sites in the world for robotic bladder removal and reconstruction. For qualified patients, City of Hope offers an
artificial bladder (Neobladder)
as an option.

We are one of the few institutions performing minimally invasive robotic surgery for bladder cancer on a routine basis, and our physicians have performed more of these procedures than at any other institution in the world. Though robotic bladder removal is a complicated surgery, it has enabled us to have excellent functional and cancer survival outcomes.

As a patient at City of Hope, you have a highly experienced and dedicated team to treat you and help you cope with a bladder cancer diagnosis. From a patient’s first visit, treatments are coordinated among all the physicians involved in the individual’s care. This is crucial, because many
bladder cancer treatment plans
involve a combination of chemotherapy and surgery. Working closely and collaboratively, City of Hope urologic surgeons and medical oncologists are in constant communication to help guide patients through their various stages of bladder cancer treatment. Our primary goal is to cure patients of the cancer, but also to create a quality of life that is at least equal to what each patient had prior to surgery.

About Bladder Cancer

There are three types of bladder cancer that begin in cells in the lining of the bladder. These cancers are named for the type of cells that become malignant (cancerous):

Transitional cell carcinoma: Cancer that begins in cells in the innermost tissue layer of the bladder. These cells are able to stretch when the bladder is full and shrink when it is emptied. Most bladder cancers begin in the transitional cells.

Squamous cell carcinoma: Cancer that begins in squamous cells, which are thin, flat cells that may form in the bladder after long-term infection or irritation.

Adenocarcinoma: Cancer that begins in glandular (secretory) cells that may form in the bladder after long-term irritation and inflammation.

Cancer that is confined to the lining of the bladder is called superficial bladder cancer. Cancer that begins in the transitional cells may spread through the lining of the bladder and invade the muscle wall of the bladder or spread to nearby organs and lymph nodes; this is called invasive bladder cancer.

Being exposed to certain substances at work such as rubber, certain dyes and textiles, paint, and hairdressing supplies

A diet high in fried meats and fat

Being older, male/female and white

Having an infection caused by a certain parasite

Bladder Cancer Symptoms

Possible signs of bladder cancer include blood in the urine or pain during urination. These and other symptoms may be caused by bladder cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:

Blood in the urine (slightly rusty to bright red in color).

Frequent urination, or feeling the need to urinate without being able to do so.

How We Diagnose Bladder Cancer

Urinalysis: This is a test to check the color of urine and its contents such as sugar, protein, blood and bacteria.

Intravenous pyelogram: A procedure in which dye is injected into a vein in the arm, travels through the body and collects in the bladder, which allows it to show up on X-rays.

CT or CAT (computerized axial tomography) scan: This procedure uses a computer connected to an X-ray machine to obtain detailed pictures of areas inside the body. A dye may be used to help visualize organs or tissues more clearly.

MRI (magnetic resonance imaging): MRI creates a series of detailed pictures of areas inside the body, using the combination of a powerful magnet, radio waves and computer imaging.

Cystoscopy: This procedure looks inside the bladder and urethra to check for abnormal areas. A cystoscope (a thin, lighted tube) is guided through the urethra into the bladder. Tissue samples may be taken for biopsy.

Biopsy: This is the removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. A biopsy for bladder cancer is usually done during cystoscopy. It may be possible to remove the entire tumor during biopsy.

Urine cytology: With this test, a pathologist will examine the cells found in the urine that are shed by the lining of the bladder.

Chest x-ray: An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.

City of Hope has performed more robotic radical cystectomies and robotic cystoprostatectomies than any center in the world.

Because City of Hope has specialists in all cancer-related fields in one location, patients receive greater continuity of care and more coordinated treatment planning. Our multidisciplinary team includes urologic oncological surgeons, medical oncologists and radiation oncologists who specialize in bladder cancer, working cooperatively to create the most effective treatment plan possible.

With bladder cancers, the selection of a surgical procedure depends on a cancer’s stage and grade. For non-invasive bladder cancer – cancer that has not spread to the wall of the bladder – one of the following types of surgery may be done:

Transurethral resection (TUR) with fulguration: Surgery in which a cystoscope (a thin lighted tube) is inserted into the bladder through the urethra. A tool with a small wire loop on the end is then used to remove the cancer or burn the tumor away with high-energy electricity. This is known as fulguration.

Radical cystectomy:Surgery that removes the bladder and any lymph nodes and nearby organs that contain cancer. In men, the nearby organs that are removed are the prostate and the seminal vesicles. In women, the uterus, the ovaries, and part of the vagina are removed. Sometimes, when the cancer has spread outside the bladder and cannot be completely removed, surgery to remove only the bladder may be done to reduce urinary symptoms caused by the cancer. When the bladder must be removed, the surgeon creates another way for urine to leave the body.

Segmental cystectomy:Surgery to remove part of the bladder. This surgery may be done for patients who have a low-grade tumor that has invaded the wall of the bladder but is limited to one area of the bladder. Because only a part of the bladder is removed, patients are able to urinate normally after recovering from this surgery.

For invasive bladder cancer – cancer that has spread to the wall of the bladder – the following are surgical options:

Radical cystectomy: The most common surgery for invasive bladder cancer is radical cystectomy. The doctor may also choose this type of surgery when superficial cancer involves a large part of the bladder. Radical cystectomy involves the removal of the entire bladder, the nearby lymph nodes, part of the urethra and the nearby organs that may contain cancer cells. In men, the nearby organs that are removed are the prostate, seminal vesicles, and part of the vas deferens. In women, the uterus, ovaries, fallopian tubes and part of the vagina are removed. Surgeons at City of Hope have performed more of these procedures than anyone in the world.

Urinary diversion: Many patients today who require the removal of the entire bladder are candidates for continent urinary diversion, a type of surgery that creates a new way for the body to store and pass urine. It involves complete pelvic reconstruction that allows patients to recover normal urinary function.

City of Hope is one of the few institutions in the world performing minimally invasive robotic surgery on a routine basis. To perform the surgery, five or six small incisions (ports) are used, just as in laparoscopic radical prostatectomy.

An artificial bladder, known as the neobladder, is created by the surgeon using tissues from the intestines to create a new bladder that is very similar to a normal bladder. It is connected to the urethra, which enables patients to urinate normally, eliminating the need for an external bag and allows patients to transition back to their normal life after surgery.

In patients who are candidates for pelvic reconstruction, the new bladder can be reconnected to the urethra. After the healing phase, those patients can urinate naturally (see urinary reconstruction). This portion of the operation is done completely laparoscopically and with greater precision.

Early results of this procedure indicate that blood loss is greatly reduced, and the overall physical recovery is far quicker; patients have a speedier return to normal physical activity and normal bladder control. Surgeons at City of Hope perform about 80 cystectomies per year, with 40 to 50 percent of patients receiving a neobladder, one of the highest proportion rates in the country.

Radiation Therapy

City of Hope offers the expertise of
radiation oncologists
who specialize in bladder cancer. Radiation is a form of energy that has long been used to treat many kinds of cancers. In bladder cancer, radiation may be administered to relieve pain, in combination with chemotherapy or after surgery to minimize the risk of recurrence.

Treatments in which beams of energy are directed at the tumor from an outside source are referred to as external beam radiation. At City of Hope, external beam radiation treatments may include:

Three-dimensional conformal therapy

Helical TomoTherapy

Considered the most advanced radiation therapy available, Helical TomoTherapy allows doctors to target and destroy cancer cells very precisely while sparing healthy tissues nearby. City of Hope was the first in the western U.S. to provide treatment for bladder cancer using this therapy.

Chemotherapy

City of Hope offers the expertise of medical oncologists who specialize in bladder cancer. Chemotherapy drugs are administered either intravenously or orally. Chemotherapy may be combined with other treatments, and are often used to combat cancer that has spread beyond the bladder.

Intravesical Chemotherapy: Intravesical therapy is sometimes used for patients with early-stage bladder cancers. In this treatment, anti-cancer drugs are put into the bladder through a thin, flexible tube called a catheter. Drugs given this way reach cancer cells in the bladder lining without affecting cells elsewhere, which helps limit side effects.

What is a urinary reconstruction and diversion?

The diagnosis of bladder cancer or other serious bladder disease may sometimes necessitate the surgical removal of the bladder. In this situation, it is necessary to create a new way for the patient’s body to pass urine. This type of surgery is known as urinary diversion surgery. There are several options available for patients requiring urinary diversion.

At City of Hope, in addition to the standard open surgical approach to removal of the bladder and urinary tract reconstruction, we also perform this operation using a robotic-assisted laparoscopic approach. A patient’s options for urinary diversion remain the same, regardless of the surgical approach.

The Anatomy

The normal urinary tract is made up of two kidneys, which filter the blood and remove extra water and waste through the urine. Urine is eliminated by the kidney’s collecting system (known as the renal pelvis) and travels down through tubes, called ureters, into the urinary bladder. Urine is stored in the urinary bladder until it is full and the person urinates.

When the bladder is removed, the ureters need to be surgically connected to some type of urinary diversion to drain urine. All forms of urinary diversion use a part of the body's intestinal tract.

This surgery can be performed to have the urine drain into an opening in the abdomen in either a continent or incontinent fashion, or can drain through the urethra (the tube in the penis/vagina) in a continent fashion. These options should be discussed with your physician.

Urinary Diversion Types

There are three main types of urinary diversions which are described below:

Ileal Conduit Urinary Diversion

The ileal conduit is the oldest and simplest form of urinary diversion. This is composed of a short part of ileum (small intestine) into which the ureters drain freely. The end of this ileal segment is brought out to the skin, usually in the right side of the stomach. This is called a stoma. The stoma is covered by a bag, which catches the urine as it drains from the ileal conduit.

Advantages:

Shorter surgery time

Shorter recovery time

No need for intermitten catheterization

Least risk of complications

Disadvantages:

External bag with possible leakage and odor.

Urine back-up (reflux) to kidneys, leading to possible infections, stones and kidney damage over time.

Indiana Pouch Reservoir

City of Hope is one of the leaders in Indiana pouch urinary diversions and have been performing this type of continent urinary diversions for many years. In this form of urinary diversion, a reservoir (pouch) is constructed out of the right colon (large intestine) and a small segment of ileum (small intestine).

A short piece of small intestine is brought out to the skin as a small stoma. A one way valve mechanism is created so that urine is kept inside the reservoir (pouch) and will not leak out to the skin.

A bag is not required and the patient simply wears a bandage over the stoma. At specific times during the day, usually every four to six hours, the patient passes a small thin catheter (tube) through the stoma, into the pouch, and empties the urine.

Advantages:

Urine is kept inside the body until it is ready to be emptied

No bag necessary

No odor

Minimal risk of leaking

Small stoma which can be covered by a bandage.

Disadvantages:

Longer surgery time

Need for intermittent catheterization (passing a small plastic tube into the pouch every four to six hours to empty it)

In some patients, it is possible to safely connect a reservoir (pouch) made of small intestine to the urethra, allowing the patient to void in a manner similar to before surgery. The reservoir (pouch) is made to mimic the normal storage function of the urinary bladder.

The patient is able to pass urine through the urethra, although there is a period of incontinence (leakage of urine) that all patients go through following this surgery.

It may take some patients 12 to 18 months to regain control of their urination. A small but not insignificant percentage of patients will have persistent incontinence.

Rarely, a patient may not be able to empty this reservoir (pouch) well and will require intermittent catheterization (placement of a small tube into the urethra) in order to empty the reservoir (pouch). Some patients will be required to do this several times a day for a prolonged time period and in some cases permanently.

In order to be considered for this sort of reservoir (pouch) there must be no evidence of cancer at the urethra at the time of surgery, and patients must be willing and able to pass a catheter into the urethra to empty the reservoir (pouch) if necessary.

Advantages:

The patient is able to empty the reservoir (pouch) of urine in a manner similar to the normal voiding pattern

No stoma is required

No catheters required

Disadvantages:

Slightly longer surgery time

Potential for temporary or permanent incontinence in a small percentage of patients.

Some patients may have to perform intermittent catheterization (place plastic tube via the urethra into pouch every six hours to drain urine) for a prolonged time period and, possibly, forever.

Living with an Urinary Diversion

After surgery, patients need time to feel well again and to regain their strength. There will be a need for physical, psychological and social rehabilitation. Not only is the goal of the surgery to cure or eliminate the disease or defect, but to enable patients to enjoy life and go back to their work and hobbies.

There may be times after surgery when patients feel discouraged or depressed. These are common feelings after this type of surgery. Discussing these feelings with family and friends may help patients overcome these emotions and return to “normal” living again soon. In addition, support groups are available for patients who have urinary diversion. Your City of Hope doctor can provide a referral.

As with all changes in life, there will be an adjustment period for patients with a urinary diversion. Patience and acceptance for the diversion will help this period to pass quickly. Patients should refer any and all questions regarding the urinary diversion to their doctors or the doctors’ assistants; no question is too small or insignificant. The goal is for the individual to return to his or her accepted lifestyle as soon as possible.

Talking about a Urinary Diversion

Patients may wonder how other people will accept them after they find out that they have a urinary diversion. It is a normal concern to wonder how to explain the surgery to others. Patients can tell their friends and family as much as they want them to know. Patients do not have to explain the surgery to everyone who asks.

If a patient is considering marriage or a long-term relationship, thorough discussions with the future partner about life with a urinary diversion and its effect on sex, children and family acceptance are in order. Open discussions with the doctor and other couples, in which one partner has a urinary diversion, can help to clarify the situation.

True friendships and relationships are built on trust and understanding, and a person’s ability to be in such a relationship does not change due to a urinary diversion.

Working and Maintaining an Active Lifestyle

People with urinary diversions can do most jobs; however, there are job hazards, heavy lifting can cause a stoma to herniate or protrude. A sudden blow near the stoma could also cause damage. Patients should check with their doctors about their type of work and any type of job hazards they should be aware of or try to avoid.

People with urinary diversions can be as active as they were before surgery. Whatever activity a patient enjoyed before surgery can be enjoyed again, once the post-operative course is completed. People with urinary diversions can continue to participate in sports, though they should consult their doctors regarding sporting hazards and protective equipment for their individualized needs.

Dietary Restrictions

There are no eating restrictions due to a urinary diversion. The urinary and digestive tracts are entirely separate. If there is a special dietary concern, the doctor will discuss it with the patient. Patients are encouraged to drink ample amount of fluids.

Travel

All types of travel and vacation are open for people with urinary diversions. Patients should make sure to take enough supplies, as there may not be a place to purchase needed items. Patients should pack supplies in a cool environment, and travel fully prepared!

Bladder Cancer Resources

City of Hope is committed to the philosophy of healing the whole person throughout treatment and recovery from cancer.

All of bladder cancer our patients have access to the
Sheri & Les Biller Patient and Family Resource Center,
which offers a wide array of support and educational services. Patients and loved ones may work with a coordinated group of social workers, psychiatrists, psychologists, patient navigators, pain management specialists and spiritual care providers at the center, as well as participate in programs such as music therapy, meditation and many others.

1-866-746-4282 The American Urological Association (AUA) is the premier professional association for the advancement of urologic patient care, and works to ensure that its members are current on the latest research and practices in urology.

The National Comprehensive Cancer Network, an alliance of 19 of the world's leading cancer centers, is an authoritative source of information to help patients and health professionals make informed decisions about cancer care.

The National Institutes of Health (NIH) is one of the world's foremost medical research centers, and the Federal focal point for medical research in the United States. The NIH, comprising 27 separate institutes and centers, is one of eight health agencies of the Public Health Service, which, in turn, is part of the U.S. Department of Health & Human Services.

City of Hope Bladder Cancer Research and Clinical Trials

Patients with an advanced stage of bladder cancer can find new hope at City of Hope, where we have long been a leader in bladder cancer research. Multiple clinical trials are ongoing, offering patients access to new and advanced treatments involving chemotherapy, radioimmunotherapy and radiation. City of Hope also maintains a large database of bladder cancer outcomes that aid in developing new treatment protocols.

Here are a few of the most promising trials underway:

Bladder Cancer Clinical Trials

Gene therapy
City of Hope investigators are collaborating on two studies that use an entirely novel approach to treating bladder cancer that has spread outside of the bladder. This approach entails the use of a drug that shuts down the genes that allow the cancer cell to respond under conditions of stress.

Natural compounds (halichondrin)
In association with a group of California-based institutions, City of Hope is exploring the activity of a derivative from a sea sponge that can potentially have a profound effect on bladder cancer growth.

Investigators at City of Hope have received grants to examine the biologic features of bladder cancer. Specifically, they are examining tissue outside of the bladder (such as lymph nodes) to determine if there are characteristics that can show a predisposition to the spreading of the cancer. The grant will allow them to gather patient samples from more than 600 individuals across the country who were treated for bladder cancer.

Scientists at City of Hope are involved in pioneering research that will set the stage for the next generation of medical advances. These studies are in the emerging fields of molecular biology, molecular genetics, nanoscience and nanotechnology.

Molecular biology research has two goals. One set of experiments is aimed at understanding how the RNA used by human cells to copy the ends of chromosomes is made and assembled in normal cells and cancer cells. The second set of experiments is aimed at understanding how patterns of methyl groups on DNA are lost and miscopied as we age and as cancer cells form.

The molecular genetics research is aimed at understanding how prostate cancer cells interfere with normal pathways in the synthesis of the building blocks of fat. Normally these pathways tell a cell that is about to become a cancer cell that it should stop growing and die in order to best preserve the whole body. Cancer cells, on the other hand, have special genes that block this process allowing them to continue to grow and ultimately form a cancerous growth.

The nanotechnology research seeks to exploit City of Hope’s patented bionanotechnology to use engineered DNA and protein to build tiny programmable machines (smaller than one thousandth the width of a human hair) that can find cancer cells and either mark them in a diagnostic procedure or perhaps selectively destroy them.

Bladder Cancer Team

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Bladder Cancer

Bladder Cancer

Bladder cancer is a disease in which malignant (cancer) cells form in the tissues of the bladder.

Specialists at City of Hope are internationally recognized experts in the treatment of bladder cancer. As one of a handful of institutes to attain the elite designation of
Comprehensive Cancer Center by the National Cancer Institute,
City of Hope is acknowledged as a leader in cancer research and treatment.

City of Hope also offers numerous
bladder cancer clinical trials
and is constantly working to develop and deliver the latest treatment strategies for any stage of bladder cancer.

Bladder Cancer Treatment Highlights

We are among the most experienced sites in the world for robotic bladder removal and reconstruction. For qualified patients, City of Hope offers an
artificial bladder (Neobladder)
as an option.

We are one of the few institutions performing minimally invasive robotic surgery for bladder cancer on a routine basis, and our physicians have performed more of these procedures than at any other institution in the world. Though robotic bladder removal is a complicated surgery, it has enabled us to have excellent functional and cancer survival outcomes.

As a patient at City of Hope, you have a highly experienced and dedicated team to treat you and help you cope with a bladder cancer diagnosis. From a patient’s first visit, treatments are coordinated among all the physicians involved in the individual’s care. This is crucial, because many
bladder cancer treatment plans
involve a combination of chemotherapy and surgery. Working closely and collaboratively, City of Hope urologic surgeons and medical oncologists are in constant communication to help guide patients through their various stages of bladder cancer treatment. Our primary goal is to cure patients of the cancer, but also to create a quality of life that is at least equal to what each patient had prior to surgery.

About Bladder Cancer

There are three types of bladder cancer that begin in cells in the lining of the bladder. These cancers are named for the type of cells that become malignant (cancerous):

Transitional cell carcinoma: Cancer that begins in cells in the innermost tissue layer of the bladder. These cells are able to stretch when the bladder is full and shrink when it is emptied. Most bladder cancers begin in the transitional cells.

Squamous cell carcinoma: Cancer that begins in squamous cells, which are thin, flat cells that may form in the bladder after long-term infection or irritation.

Adenocarcinoma: Cancer that begins in glandular (secretory) cells that may form in the bladder after long-term irritation and inflammation.

Cancer that is confined to the lining of the bladder is called superficial bladder cancer. Cancer that begins in the transitional cells may spread through the lining of the bladder and invade the muscle wall of the bladder or spread to nearby organs and lymph nodes; this is called invasive bladder cancer.

Being exposed to certain substances at work such as rubber, certain dyes and textiles, paint, and hairdressing supplies

A diet high in fried meats and fat

Being older, male/female and white

Having an infection caused by a certain parasite

Bladder Cancer Symptoms

Possible signs of bladder cancer include blood in the urine or pain during urination. These and other symptoms may be caused by bladder cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:

Blood in the urine (slightly rusty to bright red in color).

Frequent urination, or feeling the need to urinate without being able to do so.

How We Diagnose Bladder Cancer

How We Diagnose Bladder Cancer

Urinalysis: This is a test to check the color of urine and its contents such as sugar, protein, blood and bacteria.

Intravenous pyelogram: A procedure in which dye is injected into a vein in the arm, travels through the body and collects in the bladder, which allows it to show up on X-rays.

CT or CAT (computerized axial tomography) scan: This procedure uses a computer connected to an X-ray machine to obtain detailed pictures of areas inside the body. A dye may be used to help visualize organs or tissues more clearly.

MRI (magnetic resonance imaging): MRI creates a series of detailed pictures of areas inside the body, using the combination of a powerful magnet, radio waves and computer imaging.

Cystoscopy: This procedure looks inside the bladder and urethra to check for abnormal areas. A cystoscope (a thin, lighted tube) is guided through the urethra into the bladder. Tissue samples may be taken for biopsy.

Biopsy: This is the removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. A biopsy for bladder cancer is usually done during cystoscopy. It may be possible to remove the entire tumor during biopsy.

Urine cytology: With this test, a pathologist will examine the cells found in the urine that are shed by the lining of the bladder.

Chest x-ray: An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.

City of Hope has performed more robotic radical cystectomies and robotic cystoprostatectomies than any center in the world.

Because City of Hope has specialists in all cancer-related fields in one location, patients receive greater continuity of care and more coordinated treatment planning. Our multidisciplinary team includes urologic oncological surgeons, medical oncologists and radiation oncologists who specialize in bladder cancer, working cooperatively to create the most effective treatment plan possible.

With bladder cancers, the selection of a surgical procedure depends on a cancer’s stage and grade. For non-invasive bladder cancer – cancer that has not spread to the wall of the bladder – one of the following types of surgery may be done:

Transurethral resection (TUR) with fulguration: Surgery in which a cystoscope (a thin lighted tube) is inserted into the bladder through the urethra. A tool with a small wire loop on the end is then used to remove the cancer or burn the tumor away with high-energy electricity. This is known as fulguration.

Radical cystectomy:Surgery that removes the bladder and any lymph nodes and nearby organs that contain cancer. In men, the nearby organs that are removed are the prostate and the seminal vesicles. In women, the uterus, the ovaries, and part of the vagina are removed. Sometimes, when the cancer has spread outside the bladder and cannot be completely removed, surgery to remove only the bladder may be done to reduce urinary symptoms caused by the cancer. When the bladder must be removed, the surgeon creates another way for urine to leave the body.

Segmental cystectomy:Surgery to remove part of the bladder. This surgery may be done for patients who have a low-grade tumor that has invaded the wall of the bladder but is limited to one area of the bladder. Because only a part of the bladder is removed, patients are able to urinate normally after recovering from this surgery.

For invasive bladder cancer – cancer that has spread to the wall of the bladder – the following are surgical options:

Radical cystectomy: The most common surgery for invasive bladder cancer is radical cystectomy. The doctor may also choose this type of surgery when superficial cancer involves a large part of the bladder. Radical cystectomy involves the removal of the entire bladder, the nearby lymph nodes, part of the urethra and the nearby organs that may contain cancer cells. In men, the nearby organs that are removed are the prostate, seminal vesicles, and part of the vas deferens. In women, the uterus, ovaries, fallopian tubes and part of the vagina are removed. Surgeons at City of Hope have performed more of these procedures than anyone in the world.

Urinary diversion: Many patients today who require the removal of the entire bladder are candidates for continent urinary diversion, a type of surgery that creates a new way for the body to store and pass urine. It involves complete pelvic reconstruction that allows patients to recover normal urinary function.

City of Hope is one of the few institutions in the world performing minimally invasive robotic surgery on a routine basis. To perform the surgery, five or six small incisions (ports) are used, just as in laparoscopic radical prostatectomy.

An artificial bladder, known as the neobladder, is created by the surgeon using tissues from the intestines to create a new bladder that is very similar to a normal bladder. It is connected to the urethra, which enables patients to urinate normally, eliminating the need for an external bag and allows patients to transition back to their normal life after surgery.

In patients who are candidates for pelvic reconstruction, the new bladder can be reconnected to the urethra. After the healing phase, those patients can urinate naturally (see urinary reconstruction). This portion of the operation is done completely laparoscopically and with greater precision.

Early results of this procedure indicate that blood loss is greatly reduced, and the overall physical recovery is far quicker; patients have a speedier return to normal physical activity and normal bladder control. Surgeons at City of Hope perform about 80 cystectomies per year, with 40 to 50 percent of patients receiving a neobladder, one of the highest proportion rates in the country.

Radiation Therapy

City of Hope offers the expertise of
radiation oncologists
who specialize in bladder cancer. Radiation is a form of energy that has long been used to treat many kinds of cancers. In bladder cancer, radiation may be administered to relieve pain, in combination with chemotherapy or after surgery to minimize the risk of recurrence.

Treatments in which beams of energy are directed at the tumor from an outside source are referred to as external beam radiation. At City of Hope, external beam radiation treatments may include:

Three-dimensional conformal therapy

Helical TomoTherapy

Considered the most advanced radiation therapy available, Helical TomoTherapy allows doctors to target and destroy cancer cells very precisely while sparing healthy tissues nearby. City of Hope was the first in the western U.S. to provide treatment for bladder cancer using this therapy.

Chemotherapy

City of Hope offers the expertise of medical oncologists who specialize in bladder cancer. Chemotherapy drugs are administered either intravenously or orally. Chemotherapy may be combined with other treatments, and are often used to combat cancer that has spread beyond the bladder.

Intravesical Chemotherapy: Intravesical therapy is sometimes used for patients with early-stage bladder cancers. In this treatment, anti-cancer drugs are put into the bladder through a thin, flexible tube called a catheter. Drugs given this way reach cancer cells in the bladder lining without affecting cells elsewhere, which helps limit side effects.

Urinary Diversion

What is a urinary reconstruction and diversion?

The diagnosis of bladder cancer or other serious bladder disease may sometimes necessitate the surgical removal of the bladder. In this situation, it is necessary to create a new way for the patient’s body to pass urine. This type of surgery is known as urinary diversion surgery. There are several options available for patients requiring urinary diversion.

At City of Hope, in addition to the standard open surgical approach to removal of the bladder and urinary tract reconstruction, we also perform this operation using a robotic-assisted laparoscopic approach. A patient’s options for urinary diversion remain the same, regardless of the surgical approach.

The Anatomy

The normal urinary tract is made up of two kidneys, which filter the blood and remove extra water and waste through the urine. Urine is eliminated by the kidney’s collecting system (known as the renal pelvis) and travels down through tubes, called ureters, into the urinary bladder. Urine is stored in the urinary bladder until it is full and the person urinates.

When the bladder is removed, the ureters need to be surgically connected to some type of urinary diversion to drain urine. All forms of urinary diversion use a part of the body's intestinal tract.

This surgery can be performed to have the urine drain into an opening in the abdomen in either a continent or incontinent fashion, or can drain through the urethra (the tube in the penis/vagina) in a continent fashion. These options should be discussed with your physician.

Urinary Diversion Types

Urinary Diversion Types

There are three main types of urinary diversions which are described below:

Ileal Conduit Urinary Diversion

The ileal conduit is the oldest and simplest form of urinary diversion. This is composed of a short part of ileum (small intestine) into which the ureters drain freely. The end of this ileal segment is brought out to the skin, usually in the right side of the stomach. This is called a stoma. The stoma is covered by a bag, which catches the urine as it drains from the ileal conduit.

Advantages:

Shorter surgery time

Shorter recovery time

No need for intermitten catheterization

Least risk of complications

Disadvantages:

External bag with possible leakage and odor.

Urine back-up (reflux) to kidneys, leading to possible infections, stones and kidney damage over time.

Indiana Pouch Reservoir

City of Hope is one of the leaders in Indiana pouch urinary diversions and have been performing this type of continent urinary diversions for many years. In this form of urinary diversion, a reservoir (pouch) is constructed out of the right colon (large intestine) and a small segment of ileum (small intestine).

A short piece of small intestine is brought out to the skin as a small stoma. A one way valve mechanism is created so that urine is kept inside the reservoir (pouch) and will not leak out to the skin.

A bag is not required and the patient simply wears a bandage over the stoma. At specific times during the day, usually every four to six hours, the patient passes a small thin catheter (tube) through the stoma, into the pouch, and empties the urine.

Advantages:

Urine is kept inside the body until it is ready to be emptied

No bag necessary

No odor

Minimal risk of leaking

Small stoma which can be covered by a bandage.

Disadvantages:

Longer surgery time

Need for intermittent catheterization (passing a small plastic tube into the pouch every four to six hours to empty it)

In some patients, it is possible to safely connect a reservoir (pouch) made of small intestine to the urethra, allowing the patient to void in a manner similar to before surgery. The reservoir (pouch) is made to mimic the normal storage function of the urinary bladder.

The patient is able to pass urine through the urethra, although there is a period of incontinence (leakage of urine) that all patients go through following this surgery.

It may take some patients 12 to 18 months to regain control of their urination. A small but not insignificant percentage of patients will have persistent incontinence.

Rarely, a patient may not be able to empty this reservoir (pouch) well and will require intermittent catheterization (placement of a small tube into the urethra) in order to empty the reservoir (pouch). Some patients will be required to do this several times a day for a prolonged time period and in some cases permanently.

In order to be considered for this sort of reservoir (pouch) there must be no evidence of cancer at the urethra at the time of surgery, and patients must be willing and able to pass a catheter into the urethra to empty the reservoir (pouch) if necessary.

Advantages:

The patient is able to empty the reservoir (pouch) of urine in a manner similar to the normal voiding pattern

No stoma is required

No catheters required

Disadvantages:

Slightly longer surgery time

Potential for temporary or permanent incontinence in a small percentage of patients.

Some patients may have to perform intermittent catheterization (place plastic tube via the urethra into pouch every six hours to drain urine) for a prolonged time period and, possibly, forever.

Living with an Urinary Diversion

Living with an Urinary Diversion

After surgery, patients need time to feel well again and to regain their strength. There will be a need for physical, psychological and social rehabilitation. Not only is the goal of the surgery to cure or eliminate the disease or defect, but to enable patients to enjoy life and go back to their work and hobbies.

There may be times after surgery when patients feel discouraged or depressed. These are common feelings after this type of surgery. Discussing these feelings with family and friends may help patients overcome these emotions and return to “normal” living again soon. In addition, support groups are available for patients who have urinary diversion. Your City of Hope doctor can provide a referral.

As with all changes in life, there will be an adjustment period for patients with a urinary diversion. Patience and acceptance for the diversion will help this period to pass quickly. Patients should refer any and all questions regarding the urinary diversion to their doctors or the doctors’ assistants; no question is too small or insignificant. The goal is for the individual to return to his or her accepted lifestyle as soon as possible.

Talking about a Urinary Diversion

Patients may wonder how other people will accept them after they find out that they have a urinary diversion. It is a normal concern to wonder how to explain the surgery to others. Patients can tell their friends and family as much as they want them to know. Patients do not have to explain the surgery to everyone who asks.

If a patient is considering marriage or a long-term relationship, thorough discussions with the future partner about life with a urinary diversion and its effect on sex, children and family acceptance are in order. Open discussions with the doctor and other couples, in which one partner has a urinary diversion, can help to clarify the situation.

True friendships and relationships are built on trust and understanding, and a person’s ability to be in such a relationship does not change due to a urinary diversion.

Working and Maintaining an Active Lifestyle

People with urinary diversions can do most jobs; however, there are job hazards, heavy lifting can cause a stoma to herniate or protrude. A sudden blow near the stoma could also cause damage. Patients should check with their doctors about their type of work and any type of job hazards they should be aware of or try to avoid.

People with urinary diversions can be as active as they were before surgery. Whatever activity a patient enjoyed before surgery can be enjoyed again, once the post-operative course is completed. People with urinary diversions can continue to participate in sports, though they should consult their doctors regarding sporting hazards and protective equipment for their individualized needs.

Dietary Restrictions

There are no eating restrictions due to a urinary diversion. The urinary and digestive tracts are entirely separate. If there is a special dietary concern, the doctor will discuss it with the patient. Patients are encouraged to drink ample amount of fluids.

Travel

All types of travel and vacation are open for people with urinary diversions. Patients should make sure to take enough supplies, as there may not be a place to purchase needed items. Patients should pack supplies in a cool environment, and travel fully prepared!

Bladder Cancer Resources

Bladder Cancer Resources

City of Hope is committed to the philosophy of healing the whole person throughout treatment and recovery from cancer.

All of bladder cancer our patients have access to the
Sheri & Les Biller Patient and Family Resource Center,
which offers a wide array of support and educational services. Patients and loved ones may work with a coordinated group of social workers, psychiatrists, psychologists, patient navigators, pain management specialists and spiritual care providers at the center, as well as participate in programs such as music therapy, meditation and many others.

1-866-746-4282 The American Urological Association (AUA) is the premier professional association for the advancement of urologic patient care, and works to ensure that its members are current on the latest research and practices in urology.

The National Comprehensive Cancer Network, an alliance of 19 of the world's leading cancer centers, is an authoritative source of information to help patients and health professionals make informed decisions about cancer care.

The National Institutes of Health (NIH) is one of the world's foremost medical research centers, and the Federal focal point for medical research in the United States. The NIH, comprising 27 separate institutes and centers, is one of eight health agencies of the Public Health Service, which, in turn, is part of the U.S. Department of Health & Human Services.

Bladder Cancer Research/Clinical Trials

City of Hope Bladder Cancer Research and Clinical Trials

Patients with an advanced stage of bladder cancer can find new hope at City of Hope, where we have long been a leader in bladder cancer research. Multiple clinical trials are ongoing, offering patients access to new and advanced treatments involving chemotherapy, radioimmunotherapy and radiation. City of Hope also maintains a large database of bladder cancer outcomes that aid in developing new treatment protocols.

Here are a few of the most promising trials underway:

Bladder Cancer Clinical Trials

Gene therapy
City of Hope investigators are collaborating on two studies that use an entirely novel approach to treating bladder cancer that has spread outside of the bladder. This approach entails the use of a drug that shuts down the genes that allow the cancer cell to respond under conditions of stress.

Natural compounds (halichondrin)
In association with a group of California-based institutions, City of Hope is exploring the activity of a derivative from a sea sponge that can potentially have a profound effect on bladder cancer growth.

Investigators at City of Hope have received grants to examine the biologic features of bladder cancer. Specifically, they are examining tissue outside of the bladder (such as lymph nodes) to determine if there are characteristics that can show a predisposition to the spreading of the cancer. The grant will allow them to gather patient samples from more than 600 individuals across the country who were treated for bladder cancer.

Scientists at City of Hope are involved in pioneering research that will set the stage for the next generation of medical advances. These studies are in the emerging fields of molecular biology, molecular genetics, nanoscience and nanotechnology.

Molecular biology research has two goals. One set of experiments is aimed at understanding how the RNA used by human cells to copy the ends of chromosomes is made and assembled in normal cells and cancer cells. The second set of experiments is aimed at understanding how patterns of methyl groups on DNA are lost and miscopied as we age and as cancer cells form.

The molecular genetics research is aimed at understanding how prostate cancer cells interfere with normal pathways in the synthesis of the building blocks of fat. Normally these pathways tell a cell that is about to become a cancer cell that it should stop growing and die in order to best preserve the whole body. Cancer cells, on the other hand, have special genes that block this process allowing them to continue to grow and ultimately form a cancerous growth.

The nanotechnology research seeks to exploit City of Hope’s patented bionanotechnology to use engineered DNA and protein to build tiny programmable machines (smaller than one thousandth the width of a human hair) that can find cancer cells and either mark them in a diagnostic procedure or perhaps selectively destroy them.

Bladder Cancer Team

Bladder Cancer Team

People

TeamMembers

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Support This Program

Support this program

It takes the help of a lot of caring people to make hope a reality for our patients. City of Hope was founded by individuals' philanthropic efforts 100 years ago. Their efforts − and those of our supporters today − have built the foundation for the care we provide and the research we conduct. It enables us to strive for new breakthroughs and better therapies − helping more people enjoy longer, better lives.

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